2011PediatricHandbook guide for residents interns and clinical clearks

PEDIATRIC SURVIVAL GUIDE For RESIDENTS, INTERNS and CLINICAL CLERKS 2011 MacPEDS MBL 2011   TABLE OF CONTENTS ADMINISTRATIVE INFORMATION Page ƒ Welcome to Pediatrics! …………………………………………………… ƒ McMaster Pediatrics Contact Information ………………………………… ƒ Paging, RTAS Information ………………………………………………… ƒ McMaster Pediatrics Daily Schedule ……………………………………… ƒ Resources: Handbooks, PDA, Websites ………………………………… 13 ƒ Dictation Instructions ……………………………………………………… 17 ƒ Pediatrics Staff Dictation Codes and Pagers …………………………… 18 PEDIATRICS AT ST JOSEPH’S HEALTHCARE ƒ SJH Pediatrics Contact Information, Paging, Door Codes, Library…… 25 ƒ SJH Daily Schedule and Responsibilities ………………………………… 26 ƒ Accommodation Services, On-call, Dictating…………………………… 27 ƒ SJH Instructions for Listening to Dictated Reports …………………… 28 PEDIATRIC INFORMATION ƒ History & Physical Examination Outline ………………………………… 31 ƒ Adolescent History ………………………………………………………… 40 ƒ Birth Weight Conversion Chart (lbs/oz Æ kg) …………………………… 43 ƒ Admission Orders …………………………………………………………… 44 ƒ Progress Note Template – Pediatrics … ………………………………… 45 ƒ Documentation ………………………………………………………… 46 ƒ Discharge Summary Template – Pediatrics ……………………………… 49 ƒ Fluids & Electrolytes ……………………………………………………… 51 ƒ Developmental Milestones ………………………………………………… 60 ƒ Immunization Schedule …………………………………………………… 63 NEONATOLOGY 64 ƒ St Joes common terms and definitions…………………………………… 65 ƒ Progress Note Template – Neonatal ………………………………………67 ƒ Discharge Summary Template – NICU / Level Nursery ……………… 68 ƒ Neonatal Resuscitation Algorithm ………………………………………… 71 ƒ Neonatal Resuscitation Drugs …………………………………………… 72 ƒ Neonatal Nutrition Guidelines Æ Enteral ………………………………….73 Æ TPN …………………………………… Æ Vitamins and Minerals ……………… ƒ Prevention of Perinatal Group B Streptococcal Disease ………… …… 82 ƒ Hypoglycemia Guidelines For At-Risk Newborns …………….………… 86 ƒ Hyperbilirubinemia (Jaundice) In Newborn Infants ≥ 35 Weeks ……… 91 FORMULARY 111 ƒ Abbreviation Guidelines – HHSC ………………………………………… 112 ƒ Safer Order Writing ………………………………………… 113 ƒ Antibacterials ………………………………………………………………… 114 ƒ Pediatric Formulary ……………………………………………………… 120 PEDIATRIC EMERGENCY MEDICINE 136 ƒ PALS Algorithms …………………………………………………………… 137 ƒ PALS Algorithm Medications ………………………………………… 140 ƒ Status Epilepticus Algorithm ……………………………………………… 142 ƒ Diabetic Ketoacidosis Guidelines ………………………………… …… 144 Pediatric Vital Signs and Glasgow Coma Scale (GCS) ………………… 146 MacPEDS MBL 2011 WELCOME TO McMASTER PEDIATRICS! This handbook was designed for the large number of residents from a variety of disciplines that rotate through pediatrics during their first year of training It may also be helpful for clinical clerks during their time on the pediatric wards, as well as for pediatric residents and elective students Hopefully this demystifies some of the ‘pediatric specific’ logistics, and gives a few practical suggestions for drug dosages and fluid requirements This is intended only to act as a guideline for general pediatrics use, and some drugs, doses, indications and monitoring requirements may differ in individual situations We would like to thank Mark Duffett (PICU pharmacist) for compiling and editing the pediatric formulary section and Dr Moyez Ladhani for editing and supporting the production of this handbook We would very much appreciate any feedback, suggestions or contributions emailed to ladhanim@mcmaster.ca MacPEDS MBL 2011 McMaster PEDIATRICS CONTACT INFORMATION Wards 3B Back 3C North 3CSouth L2N NICU L&D 4C Nursery PCCU Clinical 3F clinic 2G clinic 2Q clinic OR Reception PACU Short Stay Radiology MRI CT scan Ultrasound EEG 4U ECHO 2F GI – pH probe MacPEDS MBL 2011 76123, 76120 76345, 76344 73388, 76972 73753 76147 75050 76354 72610, 75692 75012 75011 75094, 75095 75645 75653 75564 75279 75059 73728-room 75287-reception 75316 76363 75097 Labs Stat Lab Bloodbank Coagulation Microbiology Pathology 76303 76281 76288 76311 76327 Administration Paging Admitting Bed Booking Health Records Computer support Appointments Info Desk Security Room bookings 76443 75100 75106 75112 43000 75051 75266 76444 22382 Program Assistants Postgraduates: Shirley Ferguson 75620 peded@mcmaster.ca Adriana DiFilippo 73517 adifili@mcmaster.ca Undergrad (clerks) Kim Babin 76712 pedclrk@mcmaster.ca BCT residents: Colleen Willson  26660 willsoc@mcmaster.ca Family med residents: Jennifer Frid 76024 frid@mcmaster.ca Wendy Milburn 905-575-1744 x203 milburn@mcmaster.ca Chief Residents – Pediatrics macpedschiefs@gmail.com   MacPEDS MBL 2011 PAGING To page someone from within the hospital: dial 87 enter person’s pager number (4 digits) enter call-back extension (5 digits) enter priority code (∗ * then for CODE/STAT, for ROUTINE, for ANYTIME, denotes PHYSICIAN paging) If you don’t know their pager #, wish to leave a typed message or to wait on an outside line: call x76443 To inactivate/activate your own pager: dial 87 enter your own pager # dial 08 RTAS (Rapid Telephone Access System) • For retrieval of dictated radiology reports not yet typed on Meditech Internal access x75077 To access from outside (905) 521-5077 Security code 4123# Patients ID # (9 digits) – stop report – resume play – rewind – slow down speed – disconnect from system – speed up – next report – go to start of report MacPEDS MBL 2011 Division of General Pediatrics CTU 1, and Weekly Schedule 7:15-7:45 Monday Handover Tuesday Handover Wednesday Handover Thursday Handover Friday Handover Division of General Pediatrics Grand Rounds 4E20 Resident Orientation/ Run Case Based Teaching Teaching MDCL 3020 Teaching for Pediatric Residents MDCL3020, rest of team, see patients See Patients See Patients See Patients See Patients See Patients (CTU Huddle) (CTU Huddle) (CTU Huddle) (CTU Huddle) (CTU Huddle) 10:30-12:00 Ward Rounds Ward Rounds Ward Rounds Ward Rounds 12:00-13:00 Lunch Lunch Lunch 13:00-15:00 Patient Care *MDR 1& Patient Care Patient Care/AHD 15:00-16:00 Specialty Teaching/ Bedside Case Specialty Teaching AHD 16:00-16:30 16:30-17:00 Evaluations Handover Evaluations Handover AHD Handover Ward Rounds Grand Rounds *MDR Patient Care Teaching Sessions/Bed side Case/ Radiology Rounds Evaluations Handover 8:00-9:00 9:00-10:30 (9:15-9:30) PICU Rounds Lunch Patient Care Long Cases Evaluations Handover Please refer to attached document for details of each of the above *MDR = Multidisciplinary Rounds The detailed monthly schedule for this can be found at www.macpeds.com Updated: November 2010 MacPEDS MBL 2011 Division of General Pediatrics CTU 1, CTU 2, CTU 3 Weekly  Schedule    Handover:      Handover  is  to  take  place  from  0715‐0745  hrs.      It  is  therefore  important  to  complete  a  succinct  handover  within  the  allotted  30  minutes.  The  senior  residents  should  touch  base  with  the  charge  nurses  from  3B/3C/L2N  to  review potential discharges.     CTU Huddle/Discharge Rounds:      CTU Huddle will take place each morning from 09:15 – 09:30 am Monday to  Friday  in  the  3C  conference  Room.  The  two  ward  Attendings,  the  Senior  Residents  and  Nurse  Managers  will  attend  and  discuss  potential  discharges  and bed management. Patients that can go home will be identified at this time  and discharges for these patients should occur promptly.  Discharge planning  should  always  be  occurring  and  patients  that  could  potentially  go  home  should  be  discussed  by  the  team  the  night  before.    This  would  then  be  the  time to ensure that if those patients are ready that the patients are discharged.   The Team 3 Attending will huddle with the NICU at 9:50 to discuss potential  discharges and transfers in the Communication Room in NICU.    See Patients:    During  this  time  the  team  will  see  their  assigned  patients.    The  chart  and  nursing notes should be reviewed to identify any issues that have arisen over  night.    The  patient  should  be  seen  and  examined.    All  lab  work  and  radiological procedures that are pending should be reviewed.  The house staff  should  then  come  up  with  a  plan  for  the  day  and  be  ready  to  present  that  patient during ward rounds.  It is not necessary that full notes be written at  this time, as there will be time allotted for that later in the day.    Ward Rounds:    During  ward  rounds  the  attending  paediatrician,  with/without  Senior  Resident,  and  house  staff  will  round  on  patients  for  their  team.    These  are  work rounds.  All efforts should be made to go bedside to bedside to ensure  that all patients are rounded on.  Some spontaneous teaching during rounds  MacPEDS MBL 2011 and at the bedside can occur during this time, however there is allotted time  for that later in the day.    Team 1 will start on 3B then proceed to 3C  Team 2 will start on 3C then proceed to 3B  Team 3 will start on L2N then 4C    Case Based Teaching Team 1 and Team 2:    There is allotted time for case based teaching. All three teams are required to  attend.  The residents on the team are responsible for this case based teaching.   A  Junior  Resident  should  be  assigned  by  the  Senior  Pediatric  Resident  in  advance  to  present  at  the  case  based  teaching.    The  Junior  Resident  should  present the case in an interactive manner to the rest of the teams.  After which  the  Senior  Resident  should  lead  a  discussion  on  that  topic  and  the  staff  Pediatrician  will  play  a  supervisory  role.  The  attending  pediatricians  are  to  attend  these  rounds  to  provide  input.    Please  note  that  the  case  based  teaching  times  from  8:00‐9:00  hrs  are  protected  times  for  learners  on  the  teams.  All work is to stop at 8:00 hrs and all 3 teams are to meet at that time.  If  at  all  possible  all  pages  to  learners  at  this  time  should  be  avoided.  Please  note:  patient  care  does  take  priority;  patients  waiting  for  ER  consults  etc  should not be delayed to attend these rounds.   Nurses and other health care  professionals are welcome to attend these rounds.    Resident Run Teaching:    Time has been allotted for resident run teaching on Tuesday mornings 0800‐ 0900 hrs.   These should begin  promptly  at  0800 hrs.   The  schedule  for these  sessions will be put out separately.  These sessions will review guidelines and  protocols of the CPS and the AAP.    Protected Teaching for Pediatric Residents:    On  Thursday  morning  there  will  be  protected  teaching  for  the  pediatric  resident  ONLY.    The  rest  of  the  team,  at  this  time,  will  continue  with  discharge  rounds  and  seeing  patients.    These  sessions  will  include  staff  led  case  based  teaching/bedside  teaching,  neonatal  mock  codes,  and  CanMEDS  based  sessions.    The  second  Thursday  of  each  month  will  be  morbidity  and  mortality rounds and all learners should attend these.     MacPEDS MBL 2011 Patient Care:    During  this  time  residents  will  follow  through  with  decisions  made  during  ward rounds.  They will finish charting on patients.  This is also the time for  them to get dictations done and to complete face sheets.      Teaching Sessions:    There are various teaching sessions throughout most days on the CTU. Please  refer to the CTU teaching schedule for locations – this will be posted online as  well as on the wards.     • Monday  morning  will  be  the  Division  of  General  Pediatrics  Grand  Rounds; these will be in room 4E20. ( 8am‐9am)  • Mondays  from  15:00  to  16:00  –  there  will  be  either  Bedside  Teaching  (see below) or Subspecialty teaching sessions. It is the goal during this  time  to  get  various  specialties  to  come  in  and  teach  around  patients  that are on the ward.  • Bedside case teaching. All three teams are to meet at 15:00 hours on 3C.  At  this  time  the  attendings  will  split  the  group  up  and  do  bedside  teaching. The attendings will decide how  to  split  the group  up to  get  the  maximum  out  of  these  sessions.  Although  the  Senior  Pediatric  Resident  is  expected  to  lead  these  sessions,  the  Team  1  and  2  attendings are expected to be there and provide input.  • Tuesdays  from  08:00  to  09:00  –  Resident  run  teaching  as  described  above.  • Tuesdays from 15:00 to 16:00 ‐ There will be sub‐speciality teaching for  the first 3 Tuesdays of the month.   • Wednesdays  from  08:00  to  09:00  –  The  first  Wednesday  of  the  month  will  be  an  orientation  session  for  BCTs,  Family  Med  Residents  and  PGY 1 Pediatric Residents to familiarize them with the expectations of  the  rotation.  This  is  mandatory  for  all  new  residents  on  the  CTU  service  including  pediatric  residents  who  have  not  done  wards  yet.   Case‐based  teaching  run  by  Team  1  and  2  on  the  2nd  and  3rd  Wednesdays  and  the  4th  Wednesday  of  the  month  will  be  Peds.  Cardiology teaching – “Heart to Heart”.  • Wednesday is Academic Half Day  • Thursdays from 08:00 to 09:00 – Protected teaching for Peds Residents  Only  MacPEDS MBL 2011 10 May require higher doses for patients with head injuries Must be diluted in saline only and requires in-line filter (0.22 micron) Hold feeds before and after enteral administration as continuous feeds and formula may decrease bioavailability of oral products Significantly increased free fraction in patients with hypoalbuminemia may result in underestimation of effective drug concentration and difficulty in interpretation of drug levels and toxicity may occur at “therapeutic” serum levels Therapeutic level: 40-80 micromol/L (1020 microgram/mL) Piperacillin Broad spectrum penicillin IV: 200-300 mg/kg/day ÷ q6h (maximum 16 g/day) Adjust dose interval in severe renal impairment Active against Pseudomonas aeruginosa Piperacillin/Tazobactam Broad spectrum penicillin with beta-lactamase inhibitor IV: 200-300 mg/kg/day (of piperacillin component) ÷ q6-8h Max dose is 4.5 g (4 g piperacillin + 0.5 g tazobactam) q8h Order in mg or g of piperacillin, for example, give piperacillin/tazobactam (as x mg of piperacillin component) IV q8h Adjust dosage interval for patients with severe renal impairment Active against gram positive, (including S aureus), gram negative and anerobic organisms Potassium Chloride Electrolyte Treatment of hypokalemia: PO: 1-2 mEq/kg/day ÷ q6-12h IV: 0.25-1 mEq/kg/dose Risk of arrhythmias and cardiac arrest with rapid IV administration Dose recommendations assume normal renal function Maximum rate of administration in PICU is 0.5 mEq/kg/h (maximum 20 mEq/h) Use 0.1 mEq/mL for peripheral use, 0.2 mEq/mL for central lines For maintenance fluids the usual maximum concentration for a peripheral IV is 40 mEq/L MacPEDS MBL 2011 132 Prednisone or Prednisolone Corticosteroid Acute asthma: PO: 1-2 mg/kg q24h Anti-inflammatory or immunosuppressive: PO: 0.5-2 mg/kg 24h, dose may be tapered as tolerated mg Prednisone = mg Prednisolone Discontinuation of therapy >14 days requires gradual tapering Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy Prolonged weakness may occur when corticosteroids are used concurrently with nondepolarizing neuromuscular blocking agents Racemic Epinephrine See epinephrine Ranitidine H2 receptor antagonist Reduction of gastric acid secretion: IV: 2-6 mg/kg/day ÷ q6-12h (usual maximum 50 mg q6-8h) PO: 4-10 mg/kg/day ÷ q8-12h (usual maximum 300 mg/day) IV dose is approximately 50% of oral dose Modify dosage interval for patients with renal impairment May add daily dose to TPN MacPEDS MBL 2011 133 Salbutamol (Ventolin) Bronchodilator, β2 agonist Acute asthma: MDI: start at 2-4 puffs q20-60min prn Higher doses may be required if administered through a ventilator due to loss of drug in the circuit NEB: 0.01-0.03 mL/kg/dose (5 mg/mL solution, maximum mL) in 2-3 mL NS q½-4h, may give continuously if required IV: microgram/kg/min, increase q15min prn to maximum of 10 microgram/kg/min Maintenance therapy: MDI: 1-2 puffs q4h prn Acute treatment of hyperkalemia: IV: microgram/kg over 20 Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia) For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery Wet nebulization is less efficient and more costly Monitor serum potassium, especially with IV Cardiac monitoring required for IV use Senna Stimulant laxative PO: infants: or 2.5 mL (1.7 or 4.25 mg) q24h children: 2.5 or mL (4.25 or 8.5 mg) q24h adolescents: or 10 mL (8.5 or 17 mg) q24h Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration Also supplied as 8.6 mg tablets Spironolactone Potassium sparing diuretic PO: 1-3 mg/kg/day ÷ q8-24h Valproic Acid and Derivatives Anticonvulsant PO: 15-20 mg/kg/day increased to a maximum of 30-60 mg/kg/day ÷ q6-12h IV: Divide total daily maintenance q6h Desired therapeutic range: 350-690 micromol/L (50-100 microgram/mL) Dosing is equivalent for valproic acid, divalproex and sodium valproate MacPEDS MBL 2011 134 Vitamin K Reversal of prolonged clotting times or warfarin induced anticoagulation IV/PO: 0.5-10 mg/dose Use lower doses if there is no significant bleeding and patient will require warfarin in the future May repeat in 6-8 hours Injection may be given by mouth, undiluted or in juice or water MacPEDS MBL 2011 135 PEDIATRIC EMERGENCY MEDICINE MacPEDS MBL 2011 136 PALS: PULSELESS ARREST ALGORITHM MacPEDS MBL 2011 137 PALS: BRADYCARDIA ALGORITHM MacPEDS MBL 2011 138 PALS: TACHYCARDIA ALGORITHM WITH PULSES AND POOR PERFUSION MacPEDS MBL 2011 139 PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias Medication Adenosine Dose IV/IO: 0.1 mg/kg Max mg Repeat dose: 0.2 mg/kg Max 12 mg IV/IO: mg/kg (Max 300 mg) Supplied mg/mL: 0.03 mL/kg Max mL Repeat dose: 0.07 mL/kg Max mL 50 mg/mL: 0.1 mL/kg Max mL IV/IO: 0.02 mg/kg Min 0.1 mg Max 0.5 mg for child Max mg for adolescent ET: use 2-10 times IV dose 0.1mg/mL: 0.2 mL/kg Calcium Chloride Dextrose IV/IO: 20 mg/kg 10% solution: 0.2 mL/kg IV/IO: 0.5-1 g/kg Epinephrine IV/IO: 0.01 mg/kg ET: 0.1 mg/kg D10W: 5-10 mL/kg D50W: 1-2 mL/kg 1:10 000: 0.1 mL/kg 1:1 000: 0.1 mL/kg Amiodarone* Atropine MacPEDS MBL 2011 Administration Rapid bolus followed by rapid flush Rapid bolus for VF/VT, over 20-60 minutes for perfusing tachycardias Bolus Dilute with NS to 3-5 mL Give slow push, central line preferred Avoid hyperglycemia Bolus Dilute with NS to 3-5 mL 140 PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias Medication Lidocaine Magnesium Sulfate Naloxone Procainamide* Sodium Bicarbonate Cardioversion Defibrillation ETT size MacPEDS MBL 2011 Dose IV/IO: mg/kg ET: use 2-10 times the IV dose IV/IO Infusion: 20-50 microgram/kg/min IV/IO: 25-50 mg/kg (max g) IV/IO/IM: 0.1 mg/kg (max mg) ET: use 2-10 times the IV dose IV/IO: 15 mg/kg *do not routinely use in Combination with other drugs that prolong QT interval IV/IO: mEq/kg Supplied 20 mg/mL: 0.05 mL/kg Administration Bolus Dilute with NS to 3-5 mL Add 100 mg to Run at 1.2 - total of 100 mL mL/kg/h 0.5 g/mL: 0.05-0.1 Rapid infusion for mL/kg torsades or (max mL) severe hypomagnesemia 0.4 mg/mL: 0.25 mL/kg Bolus (max mL) Dilute with NS to 3-5 mL 100 mg/mL: 0.15 Give over 30-60 mL/kg minutes (max 10 mL) 4.2%: mL/kg 8.4%: mL/kg Give slowly and if ventilation is adequate Use 4.2% in neonates 0.5 J/kg, double dose if arrhythmia continues J/kg initially then J/kg for each subsequent defibrillation attempt (age in years /4 ) + 141 STATUS EPILEPTICUS IN INFANTS & CHILDREN THERAPEUTIC GUIDELINES TIME 0–5 mins 5-10 mins 10 -15 mins 15- 30 mins ACTION Assess Cardio-Respiratory function Open airway, provide O2 REMAIN WITH PATIENT Apply cardiac and oximetry monitors Frequently reassess airway & oxygenation ESTABLISH IV ACCESS (use intra-osseous if unable to get IV) FIRST DRUG: each given over minute LORAZEPAM (LZ) IV 0.1 mg/kg (1st choice) OR DIAZEPAM (DZ) IV 0.25 mg/kg IF NO IV: RECTAL administration of LZ or DZ at double the dose OR IM MIDAZOLAM 0.25-0.5 mg/kg Note: Diazepam and Midazolam must be followed by loading dose of Phenytoin (see below) DRAW BLOOD: cap glucose (BS), gases, lytes, Ca, Mg ± toxin screen ± Anti-Epileptic Drug (AED) levels START IV INFUSION 0.9 NaCl + Bolus of D25W 2mL/kg if immediate BS result is not available MONITOR VITAL SIGNS Reassess airway, possible need for intubation Lower body temperature if > 39 °C If available, administer PYRIDOXINE 200 mg IV before long halflife anticonvulsants are given to infants < 2years of age Repeat LORAZEPAM or DIAZEPAM dose once minutes after first dose SECOND DRUG: PHENYTOIN IV 20mg/kg in saline line (glucose will cause it to precipitate) Give over 20 minutes Monitor vital signs If seizure does not stop, give extra mg/kg IV Contact tertiary referral centre/ PICU DO NOT TRANSFER IF STILL CONVULSING! THIRD DRUG: PHENOBARBITAL IV 20mg/kg over 20 minutes Monitor vital signs Watch for apnea, especially with benzodiazepines May repeat Phenobarbital 10mg/kg twice MacPEDS MBL 2011 142 STATUS EPILEPTICUS IN INFANTS & CHILDREN THERAPEUTIC GUIDELINES (CONTINUED) 30-60 Mandatory Intubation (Rapid Sequence Intubation) and Ventilation minutes Monitor in PICU MIDAZOLAM INFUSION: Load 0.15mg/kg, then infuse at 1-2mcg/kg/min Titrate q15mins increasing by 1mcg/kg/min as needed until seizures controlled Mean range 2-4mcg/kg/min Watch BP BARBITUATE ANAESTHESIA: THIOPENTAL (Pentothal): Load 3-5mg/kg (1.5 mg/kg/min) May repeat x2 Infusion 25-400 mcg/kg/min (For burst suppression may need levels of 250 mcg/L or 1000 mmol/L) Titrate to response Watch for hypotension (common!), use inotropes PRN NOTE: PENTOBARBITAL (Nembutal): Load 3-5mg/kg over 20 minutes May repeat x2 Infusion 1-3mg/kg/hr (to maintain EEG burst suppression levels 1025mcg/ml) At 25mcg.ml there is consistent burst suppression but 60% of patients are hypotensive! Use inotropes early! • Attention to ABCs before treating the seizure • Stop seizures ASAP • Do not transfer without loading Phenytoin ± Phenobarbital • Always communicate with tertiary referral centre MacPEDS MBL 2011 143 DIABETIC KETOACIDOSIS EMERGENCY GUIDELINES MacPEDS MBL 2011 144 MacPEDS MBL 2011 145 MacPEDS MBL 2011 146 ... Mark Duffett (PICU pharmacist) for compiling and editing the pediatric formulary section and Dr Moyez Ladhani for editing and supporting the production of this handbook We would very much appreciate... General Pediatrics CTU 1, and Weekly Schedule 7:15-7:45 Monday Handover Tuesday Handover Wednesday Handover Thursday Handover Friday Handover Division of General Pediatrics Grand Rounds 4E20 Resident... as well as for pediatric residents and elective students Hopefully this demystifies some of the ‘pediatric specific’ logistics, and gives a few practical suggestions for drug dosages and fluid